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Keystone 65 Select Medical Only (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Keystone 65 Select Medical Only (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Keystone 65 Select Medical Only (HMO) in 2026, please refer to our full plan details page.
Keystone 65 Select Medical Only (HMO) is a HMO plan offered by Independence Health Group, Inc. available for enrollment in 2025 to people living in Bucks, Philadelphia Counties. This plan received an overall rating of 4 out of 5 stars in 2026.
It's important to know that Keystone 65 Select Medical Only (HMO) is a Medicare Advantage (MA) Plan without drug coverage. That means that this plan covers medical services but doesn't cover prescription drugs. If you are looking for a plan with prescription drug coverage, please search for other MA and PDP plans offered in your area.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Keystone 65 Select Medical Only (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Keystone 65 Select Medical Only (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
Drugs are not covered by this plan, so a prescription drug deductible is not applicable.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $6750.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
Prescription drugs are not covered by Keystone 65 Select Medical Only (HMO).
Additional Benefits
The Keystone 65 Select Medical Only (HMO) plan offers comprehensive healthcare coverage with no copay for primary care doctor visits and a $40 copay for specialists, both with no coinsurance. For hospital stays, members pay a $295 daily copay for days one through seven and no copay for subsequent days. Additionally, emergency services are covered worldwide with a $130 copay, and routine preventive care is available with no copay or coinsurance. Members also benefit from routine dental, vision, and hearing exams with no copay, plus a $250 annual allowance for contacts or eyeglasses. Skilled nursing facility care is covered with no copay for the first 20 days, and home health services require no copay or coinsurance. Finally, the plan provides a $30 quarterly allowance for over-the-counter items with no copay or coinsurance.
Inpatient Hospital See details
Keystone 65 Select Medical Only (HMO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring prior authorization. For both stay types, there is a $295 daily copay for days 1 through 7 and no copay for days 8 through 90, with unlimited additional acute days covered at no copay; however, upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient Services under the Keystone 65 Select Medical Only (HMO) plan are covered with no coinsurance, featuring a $390 copay for outpatient hospital services and a $250 copay for ambulatory surgical center services. Additionally, there is a $295 copay per stay for observation services, a $20 to $30 copay for outpatient substance abuse sessions, and no copay or coinsurance for outpatient blood services.
Partial Hospitalization See details
Partial hospitalization is covered by Keystone 65 Select Medical Only (HMO) with a $30.00 copay and no coinsurance. Prior authorization is required to receive these services.
Ambulance and Transportation Services See details
Keystone 65 Select Medical Only (HMO) covers ground and air ambulance services with a $250 copay and no coinsurance, subject to prior authorization. Transportation services to health-related locations are not covered.
Emergency Services See details
Keystone 65 Select Medical Only (HMO) covers emergency services with a $130 copay and urgently needed services with a $15 to $50 copay, both with no coinsurance. Worldwide emergency services are partially covered, offering worldwide emergency and urgent care for a $130 copay and no coinsurance, but worldwide emergency transportation is not covered.
Primary Care See details
Keystone 65 Select Medical Only (HMO) offers primary care physician services with no copay and no coinsurance, while specialist visits require a $40 copay and no coinsurance. Additional benefits like physical therapy, mental health, and podiatry are covered with copays ranging from $5 to $40 and no coinsurance, though chiropractic benefits are only partially covered as other chiropractic services are not covered.
Preventive Services See details
Preventive services under the Keystone 65 Select Medical Only (HMO) plan are partially covered with no copays and no coinsurance for annual physical exams, kidney disease education, and select supplemental benefits like fitness programs. However, several sub-services are not covered, including personal emergency response systems, weight management programs, therapeutic massages, and in-home safety assessments.
Hearing Services See details
Keystone 65 Select Medical Only (HMO) partially covers hearing services with no deductibles and no coinsurance, offering routine exams and fitting evaluations for no copay, and Medicare-covered exams for a $40 copay. Up to two prescription hearing aids are covered per year with a copay of $499 to $799 and no coinsurance, though OTC, inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
Keystone 65 Select Medical Only (HMO) partially covers vision services with no deductibles or coinsurance, offering annual routine eye exams with no copay and other eye exams for a $0 to $40 copay, though other eye exam services are not covered. Eyewear is covered with no copay up to a $250 annual limit for one pair of contact lenses or eyeglasses, but individual eyeglass lenses, frames, and upgrades are not covered.
Dental Services See details
Keystone 65 Select Medical Only (HMO) partially covers dental services, offering Medicare-covered dental for a $40 copay and no coinsurance, and preventive care with no copay and no coinsurance. Comprehensive services are covered with no copay and 20% to 40% coinsurance up to a $1,500 annual limit, while orthodontics, maxillofacial prosthetics, other diagnostic, and other preventive dental services are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Keystone 65 Select Medical Only (HMO) with no copay, although prior authorization is required. Medicare Part B insulin drugs require a $35 copay with no coinsurance, while chemotherapy, radiation, and other Part B drugs are subject to a 0% to 20% coinsurance.
Dialysis Services See details
Keystone 65 Select Medical Only (HMO) covers dialysis services with no copay, though a 20% coinsurance applies to these services.
Medical Equipment See details
Keystone 65 Select Medical Only (HMO) covers durable medical equipment, prosthetics, and medical supplies with no copay and 20% coinsurance. Diabetic supplies and therapeutic shoes are also covered with no copay and coinsurance up to 20%, though prior authorization is required.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Keystone 65 Select Medical Only (HMO) with no coinsurance, though prior authorization is required. There is no copay for lab services, diagnostic procedures, and diagnostic radiological services, while outpatient X-rays require a $40 copay and therapeutic radiological services have a minimum copay of $85.
Home Health Services See details
Home health services are covered by Keystone 65 Select Medical Only (HMO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by Keystone 65 Select Medical Only (HMO) with no coinsurance. While some services are covered, specific options such as cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) rehabilitation services are not covered and require a $5 copay.
Skilled Nursing Facility (SNF) See details
Keystone 65 Select Medical Only (HMO) covers Skilled Nursing Facility (SNF) care with no coinsurance and requires prior authorization, but does not require a prior three-day inpatient hospital stay. There is no copay for days 1 through 20, a $218 daily copay for days 21 through 100, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Keystone 65 Select Medical Only (HMO) partially covers other services, featuring acupuncture with a $15.00 copay and no coinsurance for up to 6 treatments yearly, and over-the-counter items with no copay and no coinsurance up to a $30.00 limit every three months. Meal benefits are not covered under this plan.
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